A 55-year-old male presents to the emergency department with a chief complaint of sudden-onset chest pain. The patient reports that the pain started about 30 minutes ago while he was at home resting. He describes the pain as a heavy, crushing sensation in the center of his chest that radiates to his left arm and jaw. He also reports feeling short of breath and diaphoretic.

The patient has a history of hypertension and hyperlipidemia, for which he takes medication. He is a current smoker, with a 20-pack-year history. He has no known history of coronary artery disease or previous myocardial infarction.

On physical examination, the patient appears anxious and in distress. His vital signs are as follows: blood pressure 150/90 mmHg, heart rate 110 bpm, respiratory rate 22 breaths/min, and oxygen saturation 92% on room air. Cardiovascular examination reveals normal heart sounds with no murmurs, rubs, or gallops. Lung auscultation is clear bilaterally.

Significant Positives & Negatives For Differentials

Chest Pain

Positives:

• Sudden onset of chest pain
• Chest pain radiating to the left arm or jaw
• Chest pain associated with shortness of breath, diaphoresis, or nausea
• History of coronary artery disease or other cardiovascular risk factors

Negatives:

• Chest pain that is pleuritic, positional, or reproducible with palpation
• Chest pain that is sharp, stabbing, or localized
• Absence of cardiovascular risk factors
• Normal vital signs and physical examination

Musculoskeletal Chest Wall Pain

Positives:

• Chest pain that is reproducible with palpation or movement
• Absence of other concerning symptoms like shortness of breath or diaphoresis
• Normal cardiovascular examination

Negatives:

• Sudden onset of chest pain without a clear precipitating event
• Chest pain that is not reproducible with palpation or movement
• Presence of cardiovascular risk factors or history of cardiac disease

Gastrointestinal Causes (e.g., esophageal spasm, gastroesophageal reflux disease)

Positives:

• Chest pain that is associated with swallowing, eating, or lying down
• Chest pain that is relieved by antacids or proton pump inhibitors
• Absence of cardiovascular risk factors or history of cardiac disease

Negatives:

• Chest pain that is not related to swallowing or eating
• Chest pain that is not relieved by antacids or proton pump inhibitors
• Presence of cardiovascular risk factors or history of cardiac disease

Anxiety or Panic Disorder

Positives:

• Chest pain that is associated with feelings of anxiety, fear, or panic
• Chest pain that is not associated with other concerning symptoms like shortness of breath or diaphoresis
• Absence of cardiovascular risk factors or history of cardiac disease

Negatives:

• Chest pain that is sudden and severe, without a clear precipitating event
• Chest pain that is associated with other concerning symptoms like shortness of breath or diaphoresis
• Presence of cardiovascular risk factors or history of cardiac disease

Case Presentation: Based on the patient's presentation, with sudden-onset chest pain, associated symptoms of shortness of breath and diaphoresis, and the presence of cardiovascular risk factors, the most likely diagnosis is chest pain of cardiac origin, such as acute coronary syndrome or myocardial infarction. Further evaluation with electrocardiogram, cardiac biomarkers, and potentially imaging would be necessary to confirm the diagnosis and guide appropriate management.